Insects, people and disease: Adolpho Lutz and tropical medicine

One thing makes a great impression on me … The Americans

showed that the blood is virulent, and microscopic examination

does not reveal anything that one could relate to a parasitical

form. Under these circumstances, it would be necessary to shift

investigations to invisible viruses. The experiment to be carried

out would be to filter serum or blood diluted in water and

inoculate the filtrate in a man. I know it is not possible to perform

such an experiment in Rio, and I feel quite uncomfortable in

suggesting an experiment that targets an invisible virus … In

brief, it is necessary to try inoculating monkeys … It is

necessary to try all the different inoculation methods: intra-

cerebral, intravenous, etc. (ibid., p.57)

As Tran shows (1998), in May 1902, Simond, Marchoux, and Salimbeni began a series of experiments, at first with rabbits and later with five species of monkeys. They injected not only suspect parasites but also the bodies and salivary glands of infected Stegomyia; they then made these mosquitoes bite the animals. None of the experiments brought them any results, thus reinforcing the supposition that yellow fever was a disease that, apart from humans, did not have any other vertebrate host.

Otto and Neumann reiterated this suspicion and yet another of the Frenchmen's observations: its germ could pass on to the offspring of the mosquito who had bitten a sick person, but the insect that had been contaminated by heredity could only “expel” the germ after twenty-two days (instead of the twelve days it took the mosquito that had been infected directly).

In spite of their time spent at the microscope, the two German doctors failed to determine the etiological agent. In their report (1906), they mentioned all the microbes that had been found in the blood and tissues of the sick: the Richardson, Gibier, Havelburg, and Sanarelli bacilli; the Freire, Finlay, and Delgado micrococci; the Carmona y Valle and Lacerda fungi. Although they were convinced of these microorganisms’ irrelevance (already invalidated by Sternberg in 1890), they checked for the microorganism's appearance in material collected from the ill and from autopsies – especially the Sanarelli bacillus, which was vigorously defended by doctors in Rio de Janeiro and São Paulo. They also looked for an organism similar to the influenza organism that had been described in 1902 by Durham and Myers, and which Laveran proposed to the Biology Society of Paris that same year. The results of Otto and Neumann's research were negative for all these microbes.

It was, however, indisputable that there was a very small organism in the blood of the sick, since it was possible to transmit yellow fever to healthy people by inoculating them with that organic liquid, even if partially defibrinated, or with serum diluted in sterilized water, after passing through a Berkefeld filter, capable of retaining the smallest bacteria. It had already been determined by the U.S. and French commissions that this effect failed to occur if the blood sample were heated to 55°C for five minutes, or if it were used after the third day of onset of illness. Simond, Marchoux, and Salimbeni had also verified that the serum would lose its virulence if exposed to air for over forty-eight hours, even if not heated. Defibrinated blood kept from contact with the air could still produce yellow fever after five days, but after eight days it could be injected harmlessly.

Much like the French, Otto and Neumann did not obtain any results from microscopic examination of fresh and stained preparations of infected Stegomyia.

They then targeted a hypothesis raised by Fritz Richard Schaudinn, a protozoologist at Hamburg's Marine and Tropical Diseases Institute who was one step away from discovering the cause of syphilis:

Treponema pallidum.142 The agent of yellow fever could also be a spirochaeta. During a stage of this protozoan's development, structures would form that were so minuscule that they might easily pass through a bacterial filter. Yet none of this barred the possibility that at a later stage they could take on visible forms not yet recognized as specific to yellow fever.

“Our main lines of research were subsequently defined according to this premise.” To conduct their investigations, Otto and Neumann had brought with them a technological novelty that piqued great curiosity among both French and Brazilian doctors: an “ultra-microscope,” one of the first Fritz Schaudinn (1871-1906) to be manufactured by Zeiss. The lab received frequent visits of doctors and lay people interested in seeing the instrument; physicians from “São Sebastião Hospital, as well as Dr Marchoux, did not miss the chance to take a look at … our results.”

 

Fritz Schaudinn (1871-1906) (Acervo Instituto Bernhard-Nocht).

Otto and Neumann had to learn to use this apparatus that had not yet been tested in German laboratories. They had great difficulty at first. Developed by the physicists Siedentopf and Zsigmondy (1908) to make ultra-microscopic particles visible, the instrument could only be used in sunlight; the manufacturers had presumed sunlight would be abundant in the tropics, and believed they would not find good enough energy sources there. For that reason, research had to come to a halt every time a cloud blocked the sun. They also had to stop during overcast days and when trees threw their shadows across the windows in the setting sun. Working at night was out of the question.

Despite these inconveniences and the instrument's intrinsic difficulties, the German researchers were able to spot in the blood serum of sick patients a tiny corpuscle, sometimes round in shape and sometimes oval, and a hundred times smaller than a red blood cell. At times the bodies would appear in their field of vision in relatively small numbers; other times they would fill it completely. The researchers attributed this to the corpuscles’ weight, which caused them to sink to the bottom of the liquid, much like bacteria, and thus disappear from their field of vision. Only sometimes did they seem to move of their own accord.

Not convinced of the specificity of these small corpuscular elements, they examined the serum of healthy people and of patients suffering from other diseases. They found completely different corpuscles.

The unsatisfactory results of our research led us to consider

looking for a fluid inside the body where we might suppose to

find the pathological agent, but that, on the other hand, would be

more appropriate for research than blood serum … The only

fluid that met these conditions, since it is free of salts and

albumin, was cerebral-spinal fluid, which, as far as we know,

was studied by us for the first time with respect to yellow fever.

This choice was certainly related to Schaudinn's research on syphilis, a disease with well-known neurological manifestations.

They extracted lumbar fluid and repeated their ultra-microscopic examinations. In the non-centrifuged fluid, for the first time they saw tiny, very delicate bodies; unlike the forms found in blood serum, they moved about in a very lively manner, like butterflies flitting about in irregular paths, zigzagging.

They then filtered the cerebral-spinal fluid through

one of the narrowest filters (Chamberland F), which Dr.

Marchoux graciously ceded us for our work … The microscope

allowed us to recognize, in this case too, those minuscule

elements cited. On reexamining the non-filtered and filtered It would only be three decades later that the equipment that was to make the etiological agent of yellow fever visible would appear. By then, the agent had been unequivocally linked to a virus since 1927, when three researchers from the Rockefeller Foundation – Adrian Stockes, Johannes A. Bauer, and N. Paul Hudson -managed to infect rhesus monkeys of the genus Macaca in French West Africa. A rapid succession of papers by virologists from that institute would culminate in the production of an efficient vaccine in the late 1930s, and once more Brazil was to play a key role in the process (Benchimol, 2001).

blood serum taken from this patient, we were able to find them

there as well. Perhaps they had escaped us previously because

of their small number.

Encouraged, they proceeded to the experimentum crucis: they drew spinal fluid from a patient with smallpox and “a black person who happened to be in the hospital.” To their surprise and disappointment, the fluids of both control subjects displayed corpuscles very similar to those they had seen.

In the report published in 1906, they left the pathological meaning of their findings undefined.

At this point, it is not clear what they might mean … Who could

affirm that the particles seen in the yellow fever patients are no

different from those of the patients with smallpox or from healthy

people? The ultra-microscope, regrettably, is not decisive …

Any other corpuscular elements capable of provoking a certain

suspicion … could not be confirmed by it. Spirilla,

trypanosomes, and similar forms could not have escaped us,

because the minute spirilla of the chicken epidemic, described

by Marchoux (1903) and used for comparison, were impressive

for their extraordinary size.

The future will tell whether the ultra-microscope can solve the

question in other diseases whose agents are still unknown or

when research on yellow fever is taken up once again.

 

Monkey (rhesus) with a cutaneous eruption caused by syphillis

(Kolle & Hetsch, 1918, fig. 1).

Before that (1918-26), however, another germ enjoyed as much fame as Sanarelli's: Leptospira icteroides, a spirochaeta incriminated by Hideyo Noguchi (1876-1928), a bacteriologist from the Rockefeller Foundation that had become famous for successfully culturing the syphilis agent in vitro and also author of a seminal paper on the serodiagnosis of this disease.

Let us return to Simond, Marchoux, and Salimbeni. The results of

their first few months in Rio did not meet their expectations, 143 an impression heightened by the publicity given to the results of other teams formed after Reed and his collaborators had released their papers. “All our attempts at infecting a great variety of animals in the laboratory … were unsuccessful,” they wrote. “We had no alternative but to employ the method so brilliantly inaugurated by the Americans and continued with no less success in Brazil, that is, experimentation on humans” (cited in Tran, 1998, p.59).

 

Dr. Hideyo Noguchi (1876-1928) (Olpp, 1932, S299).

The first report they published states that the volunteers were warned of the risks they ran, in the presence of witnesses, and all of them agreed to submit to the experiments. Tran (1998) questions this assertion. He found no trace of “informed consent” in the documentation collected at the Pasteur Institute. It is his opinion that these immigrants, who had recently arrived from the old continent and were for the most part extremely poor, had no sense of the dangers to which they were exposed by letting themselves be bitten by infected mosquitoes, and even if they were conscious of it, they accepted it for financial reasons. Reed paid his experimental subjects generously (up to one hundred gold dollars each). Marchoux and Simond purportedly did the same. One of Simond's lab notebooks mentions “people to pay” on a page with a list of

twenty-four names. 144

It was Roux who in 1902 suggested that they perform serum therapy trials using the serum of patients recovering from the disease.

You should also make experiments on patients with blood from

those who are recovering from serious bouts of yellow fever. If

the serum proves active, do not hesitate to inject great

quantities of virulent blood in a horse to then test its serum.

If you are at all successful in this direction, it would support the

notion of a bacterial agent. In my opinion, and I repeat it yet

again, the solid immunity created by a bout of the disease

seems, in my eyes, to favor the notion of a bacteria … It is a pity

that you cannot carry out experiences on m. [men] of good will,

as in Cuba. (cited in Tran, 1998, p.58)

Experiments with men began around March 1903. Ribas and Lutz's experiments in São Paulo were still underway. Simond and Marchoux's were conducted with the approval of Oswaldo Cruz and Carlos Seidl in Petrópolis, a region similar to the capital of São Paulo in that it was exempt from yellow fever; this meant that the human subjects would have no accidental contact that risked invalidating the results.

The first three cases only served to confirm conclusions reached by the U.S. commission, as well as the conclusions Lutz had communicated to Simond:

“The São Paulo experiments … prove what you have probably observed for yourselves: that the infection is readily obtained if the necessary conditions are observed. I would be grateful if you would explain this to Messrs Metchnikoff and Roux,” the director of the

Bacteriological Institute had written in January 1903. 145

Simond and Marchoux soon turned to experiments concerning infection and immunization (Salimbeni had just returned to

France).146 On 23 March 1903, Daniel Silva received an injection of contaminated defibrinated blood that had been collected fourteen days earlier; five days later he was injected with a new dose, followed by an injection of virulent serum that brought the onset of the disease. Both doctors concluded that the inoculation of old blood did not confer immunity (Tran, 1998, p.61). On 29 March, J. Ralf and M. Hofer each received three injections of serum from sick patients, heated to 55°C, and days later the virulent serum. Ralf developed benign yellow fever and Hofer remained unaffected. This experiment did not enable the researchers to establish whether the heated virulent serum had preventive properties, or if Hofer had developed immunity previously.

In April, May, and June, Marchoux and Simond tested different preparations on around twenty-five volunteers whose ages ranged from 16 to 38. They were mostly German, Portuguese, and Italian immigrants who had arrived in Brazil within the previous six months, making it highly probable that they were not immune to the disease. In addition to heated or aged virulent serum and to virulent serum filtered through various apparati, they also experimented with the serum of convalescing patients. When applied to patients in the first days of the disease, this serum seemed to improve their state of health. Simond tallied seven successes and four failures (ibid., p.61-2).

The results of these attempts at preventive vaccination were, however, more contradictory in Tran's view (1998, p.62). At times the patients remained healthy, at times they developed yellow fever. Most of the experiments produced simple bouts of fever that were difficult to diagnose unequivocally. If the symptoms were tenuous, should the researchers conclude that the vaccination had failed or that there was relative immunity? Interpretation of the results was made even more uncertain by the absence of control groups. Simond and Marchoux alleged that they could not allow themselves this kind of luxury with human subjects.

 

Portrait of Oswaldo Gonçalves Cruz, autographed in April 1905

(Musée de l'Institut Pasteur, MP31322).

On the morning of 18 June 1903, Raymondo Geronimo, a 38-year-old Italian, was making his way down from Petrópolis to Rio de Janeiro on the 7:30 a.m. train. He felt very ill, and upon arriving at the foot of the mountains, he left the train with his suitcase in hand and began to walk the line in the opposite direction, as if he intended to return to Petrópolis. He walked for a few hundred meters, stopped, and passed out. Railroad employees carried him to the station, where he passed away after a few hours (ibid., p.63).

Geronimo was one of Simond and Marchoux's ‘human guinea pigs’. Six days earlier, he had been given an injection of virulent serum heated for 15 minutes to 48°C. On the 18th, at six in the morning, S. Bordach also died; he was a 23-year-old man from Hamburg who had arrived in Brazil a month earlier. On 10 June, he had been bitten by two infected Stegomyia and had taken seriously ill four days later. The third fatal victim was Heinrich Falk, a young Bavarian, also 23 years old; he had arrived in Rio on 1 June. On 10 June, in Petrópolis, he received one cc of virulent serum that had been passed through a Chamberland filter without being diluted. He fell ill six days later and died on 20 or 21 June. There seems to have been a fourth victim, on the same date: Lippe, a 34-year-old man from Westphalia; his name appears next to that of the other three in one of Simond's notebooks (ibid., p.62).

Neither Simond nor Marchoux made any mention of these accidents in the missions official reports published in the Annales de l'Institut Pasteur. The experiments were not completely discontinued because in 1905, as we saw, they still used a human volunteer to prove the hereditary transmission of the yellow fever virus by mosquitoes.

The complicity of the Brazilian sanitary authorities is proven beyond any doubt by a letter that Oswaldo Cruz sent to Emílio Ribas on 20 July 1903. Amid assessments of the French results, he commented:

Regarding human experimentation, they verified that:

Stegomyia transmitted the typical form of the disease.

Unfortunately, there were three deaths caused by classic

experimental yellow fever, with anuria, black vomit, jaundice,

albuminuria, etc.; the cases were verified by autopsy, and all the

characteristic lesions were found … One of the sick men

victimized by yellow fever had been bitten by only two

mosquitoes, one of which practically did not draw blood. I ask of

you complete confidentiality regarding these cases that ended in

death and which were carried out under my sole responsibility.

You will understand, my dear friend, how our adversarial press

would exploit this fact if they were informed of it. These

experiments were categorical, just as the others in which the

accompanying symptoms were as categorical as they could

possibly be.147

 

In the rough seas of sanitary practices

Nuno de Andrade, Oswaldo Cruz's predecessor at the General Directorship of Public Health, had voiced many doubts on this topic in the Jornal do Commercio (24 Aug. 1902) and in Revista Médica de São Paulo (1902). The discovery made by the North Americans added a new element to yellow fever prophylaxis, but it had failed to gather enough convincing elements to oust environmental disinfection and sanitation practices. The Havana doctrine was based on the doctrine of paludism. Neither of these accepted a microbe free in the external environment, and both restricted all the threads of the problem to humans and the mosquito. “I admit that the hypothesis that the yellow fever germ does not exist in the external environment bothers me seriously,” stated Andrade, “because scientific documents and our own observations have accumulated a world of facts that would be completely inexplicable if the deductions of American prophylaxis were accepted without restrictions.”

Andrade pointed to decisive experiments that had not been conducted and which would exclude alternative pathways of the germ. The North Americans had demonstrated that contaminated objects did not transmit the disease directly, but they had not proven that these objects did not carry the germ. No experiment had cancelled out the possibility that healthy mosquitoes could infect themselves on soiled objects and then inoculate the disease in humans. No one had investigated Stegomyia‘s excretions for possible infective properties. In the absence of such proof, the prevention formula continued to employ the term “contaminating object” as part of the equation.

The fact that the microbe remained undetermined also left the theory of its transmission exposed to other disturbing questions. “The most impressive thing about the shadowy etiology of yellow fever is that the blood injected by the syringe transmits the disease immediately … but if drawn by the mosquito, it only becomes infectious after about 12 days!” The North Americans provided an explanation that worked by analogy and did not rest on experimental proof. They supposed that the unknown microbe underwent transformations in the body of Stegomyia similar to those undergone by the malaria plasmodium inside Anopheles. The parallelism seemed arbitrary. The circumstantial fact that the mosquitoes were hosts of both germs did not imply identical life cycles. The microbe's invisibility, allied to a lack of knowledge over what went on during the interval between the mosquito's contamination and the appearance of its capacity for infection, tainted the Havana doctrine with fuzzy areas. These areas did not concern Stegomyia as an agent of transmission – Nuno de Andrade considered this a proven fact – but rather what preventive deductions could be derived from this fact.

Nor did he take the war on the mosquito in Cuba as evidence of an exclusive form of propagation, as postulated by the Americans. He considered this battle a kind of “touch-up work” that supplemented the material improvements made by the military authorities earlier. With discipline, severity, and implacable rigor against those who hid the sick, they had rectified the Havana coastline, dried up marshlands, built sewage systems, distributed great quantities of drinking water, installed electric lighting, cleaned prisons, built hospitals, intervened in residences, cleaned up the markets, and paved all of the city streets. It was not out of the question to suppose that those interventions had contributed in no small amount to the success of an initiative that was usually ascribed only to the war on mosquitoes.

The Havana doctrine, therefore, insofar as it excludes the yellow

fever germ from the environment, is a postulate or a question

mark; it does not authorize the exclusive prophylaxis that the

Americans recommend, nor does it at this point have the power

to impose disregard for the current processes of defensive

hygiene … The prophylactic formula must be a complex one,

that is, it must embrace all the processes of prophylaxis

currently in use, in addition to all those derived from the

transmissibility of yellow fever by Stegomyia. Addition and not

subtraction.

In São Paulo, too, this theory found passionate opponents. Arthur Vieira de Mendonça continued to defend the icteroid bacillus and his arguments had a marked impact on public opinion since they were expressed precisely by a bacteriologist who had, until recently, been close to Adolfo Lutz. He had worked at the Bacteriological Institute since its foundation, and had served as under-director after Lutz became head of the Institute upon Le Dantec's departure. Moreover, Mendonça was one of the founders of the Revista Medica de São Paulo, along with Victor Godinho, and had presided the Society of Medicine and Surgery of São Paulo during the most critical period of

the controversy (1903-04).148 Another of Lutz's assistants, Ivo Bandi,

would join the fray in favor of the Sanarelli bacillus. 149 In 1903, when the results of the experiments conducted at the Isolation Hospital were released, Mendonça published a book (1903) containing the letter, articles, and reports written by him and by other opponents of the theory of transmission of yellow fever by mosquitoes.

If we add Finlay's cases to those of the U.S. commission and of

São Paulo, we have a great number of sick people in which the

disease is not clearly defined and the symptoms are always

hazy and inexpressive, and yet they want medical doctors as a

class to accept the diagnosis of yellow fever … Never has Rio

de Janeiro seen such favorable conditions as now to rid itself of

yellow fever. Having the engineer Passos as Mayor provides us

with a sure guarantee that residences can be improved and

general advances made in the city, and if this were

accompanied by systematic hospital isolation and disinfections,

in very little time yellow fever would be eradicated, as it was in

Santos and Campinas.

Preference, however, has been given to a war on the mosquito,

a war that was not efficacious in a small town like São Simão;

what can one expect of it in a great city like Rio de Janeiro!

(Mendonça, 1903, p.136, cited in Almeida, 2003, p.252-3)

Controversies on the Havana theory found a concentrated forum at the 5th Brazilian Congress on Medicine and Surgery, which took place in Rio de Janeiro from 16 June to 2 July 1903, right when Oswaldo Cruz was silencing facts on the deaths resulting from the French mission's experiments. Partisans of Finlay's theory did as much as they could to make the Congress into a tribunal that would sanction it.

The reality was, however, that no one took the stand to claim that the mosquito did not transmit yellow fever. Adversaries defined themselves as “not convinced” or as “non-exclusivists.” They were intransigent in the defense of disinfection and ground sanitation, which the exclusivists wanted to abolish. Prominent in the first group, besides Ivo Bandi, were Jorge Pinto, head of the Sanitation Service for the State of Rio de Janeiro, and Pacífico Pereira, a leading figure in Bahia's Tropicalist School, who was absent but whose paper was

read during the Meeting.150 The most noteworthy “orthodox exclusivists,” or unitaristas (defenders of one sole explanation), were Felicio dos Santos, an “experienced old” general practitioner from Bahia who owned the Casa de Saúde São Sebastião hospital in Rio de Janeiro, and Drs. Plácido Barbosa and Carneiro de Mendonça, from Rio de Janeiros Public Health.

Doctors from São Paulo had decisive participations. Carlos Meyer and Arthur Palmeira Ripper read reports on the experiments conducted at that state's Isolation Hospital, along with a communication from director of the state's Sanitation Service; its

conclusions guided the final vote on deliberations.151 At the closing session, it was decided to schedule the 6th meeting in São Paulo, chaired by Emílio Ribas. A delegation from the 5 th congress accompanied the São Paulo contingent to the train station, where they were acclaimed during their departure.

The result of these negotiations of a political nature concerning an issue of a scientific nature – the truth or error of the transmission and prevention of yellow fever – turned Oswaldo Cruz's strategy into the officially sanctioned guidelines of the medical corporation. It is clear, however, that the verdict fell short of what the commanders of the anti-Culex campaign had hoped for, and the campaign had to be negotiated in many other forums, inside and outside the nation: before the Congress, the press, professional associations, international scientific institutions, various (and clashing) levels and bodies within the government administration, and the very people of the city who were targeted with successive pieces of “advice” drawn up with the intent of disseminating the new beliefs and producing a new conventional wisdom regarding the capital issues of public and individual health. The Congress of Medicine and Surgery was therefore only a cogwheel in the political machinery underlying the campaign against yellow fever, which was already in the streets. Measures derived from the Havana theory were put into practice at the same time as negotiations were going on over legal instruments, institutional arrangements, funding, consents, and symbolic endorsements. These negotiations took up the entire year of 1903 and part of 1904 and were made in the wake of events of much greater consequence than the issue of yellow fever, even though the latter had become sine qua non with the sanitation of the capital of the Republic. One can say that all regions and strata, all beings, all moveable and immoveable, recent or secular elements of the city were trampled on by the initiatives of the Director General of Public Health, Oswaldo Cruz; of Mayor Francisco Pereira Passos; and of other agents of the sanitary measures and urban remodeling of the Brazilian capital, under the administration of Brazilian President Francisco de Paula Rodrigues Alves (1902-06). The clashes, injustices, demolitions, and overbearing intrusion of the public powers in the private lives of Rio's inhabitants raised the social temperature to unprecedented heights, until the Vaccine Revolt finally erupted in November 1904.

 

Trolley turned over in República Square during the Vaccine

Rebellion. A Revista da Semana, 27.11.1904 (Carvalho, 1987).

It is not our aim here to narrate the conflicts that marked the beginning of the new century (for more on this, see Benchimol 2003, 1992; Chalhoub, 1996; Carvalho, 1987). We will content ourselves with highlighting a few changes in the repetitive pattern of events.

Defending the inclusion of mosquito-fighting measures as part of the prophylaxis formula already applied to yellow fever, in 1902, Nuno de Andrade defined their enforcement as a “world of work and a thousand worlds of struggles!” (Revista Médica de São Paulo, p.325). Reducing the formula to those equations essential to breaking just some of the links in the chain of infection presupposed a different way of thinking. The word ‘vector’ was very much in vogue within Oswaldo Cruz's group; it contained and conveyed a notion of geometry that quickly brings to mind a straight line aimed at very precise targets.

In an insightful analysis of the Pasteurian revolution, Bruno Latour (1984, 1987) replaced the supposed antagonism between the old hygiene of the miasmas and the new science of microbes with an image that entailed correcting the old actors’ course of action in the light of the strategy proposed by the new actors. This implied a reciprocal “translation” of interests that would be advantageous to both sets of actors. The old hygiene was characterized by unlimited ambition. For every targeted disease, battles had to be waged on an extremely wide array of fronts: against the forces of nature, against the topography of cities, against the most varied components of urban life. With the microbes specific to each disease in hand, the Pasteurians pinpointed their key battles – “the mandatory points of passage” – which would carry the hygienist contingents to the victories they so ardently desired. Although this seductive image can help us to think through the issues, it is the product of a distillation of accidents, mistakes, and contradictions that make the actual battles much more confusing and unruly – battles whose outcomes were not always favorable.

Rio de Janeiro in the 1910s. Avenida Central, now called Avenida

Rio Branco, was built during the Rodrigues Alves government by a

committee headed up by Paulo de Frontin, while the mayor took

charge of other “urban beautification” projects and Oswaldo Cruz was in charge of the city's sanitation. This thoroughfare, the product

of a belle époque model for Rio de Janeiro and influenced by

Haussmann's model for Paris, was inaugurated in 1904 to link the docks of the new port to Avenida Beira-Mar and ran over the ruins of

the old colonial city. Gilberto Ferrez Collection. Photo: Marc Ferrez

(Parente & Monte-Mór, 1994, p.59).

The efforts by Pasteur's followers in Brazil to address yellow fever from the perspective of specific microbes did not eliminate the plural nature of strategies against the disease, even for Domingos Freire, who aimed at yellow fever a syringe armed with his prophylaxis. One could argue that these Brazilian Pasteurians were wrong, but that would only invalidate the points of passage they established. The logic behind construction and validation of microbial theories resulted in the reiteration of most of the certainties produced by physicians and hygienists. Latour's description of the needed rectification of both direction and mentality only appeared when Oswaldo Cruz became head of Public Health. The differences can be seen in the definition of a limited number of diseases to be targeted, in the focus on the vectors of yellow fever and of the bubonic plague, and in the emphasis on vaccination – which does not escape the image of an arrow pointed at the specific flank of smallpox.

These arrows guided the action of Oswaldo Cruz's sanitary brigades and lent clarity to their initiatives in the chaotic, tumultuous context framing the urban reform and sanitation of Rio de Janeiro. We can discern its unique trajectories amidst the offensive attack that engineers were concomitantly leading against many of the targets pinpointed by public health during the previous century (and which the sanitarians now judged irrelevant). The ties that Oswaldo Lutz's sanitary campaigns were tearing asunder or patching together within a fraying social and urban fabric pushed into action, relation, or conflict a multitude of actors unforeseen when the new strategy was presented, with the simplicity of its experimental correlations, at the 5th Brazilian Congress of Medicine and Surgery. Turmoil swallowed the vaccine, the plague was subjugated, and yellow fever disappeared only momentarily in Rio de Janeiro.

 

Adolfo Lutz and microsporidia

Having intended from the very beginning to study animal haematozoons, Paul-Louis Simond, communicating with Oswaldo Cruz, had made “the most well-deserved references” to Lutz's latest paper on ophidian haematozoa. He and Marchoux reportedly said they would inevitably go to São Paulo and, “with great pleasure” meet with “the friend [they] had already come to know well through his published papers.” This information was passed to Lutz on 20 November 1901, about two weeks after the Pasteur Institute mission's arrival in Rio de Janeiro. Oswaldo Cruz was still a simple technician at the Manguinhos Serum Therapy Laboratory, where he worked in the preparation of serum and vaccine against the bubonic plague. It was only in December 1902 that he would take Pedro Affonso's place as head of this establishment. The Frenchmen never did travel to São Paulo and Lutz's opportunity to meet Simond in person came only in November 1902, when the latter came a second time to Rio, to obtain infected Stegomyia. In a letter written 9 March 1903 (two weeks before Cruz became Director General of Public Health), Simond stated:

It was with keenest interest that I read the report of the

experiments you conducted with the aid of some doctors from

São Paulo. They are of the utmost importance since this is the

first time that the mosquitos role in yellow fever has been

confirmed outside of Havana … I am no less interested in your

other papers on pebrines and on the wild plants that host

mosquito larvae. Mr. Foetterle gave me a copy of this latest

publication, for which I thank you warmly. If I decide to travel to

São Paulo, I will make certain to let you know in advance so that

I will be sure to find you in your laboratory. It is hardly necessary

to say that I would like to go strictly incognito and visit only

yourself. (BR. MN., Fundo Adolpho Lutz, pasta 174, maço 1)

This letter does not add much to what we already know about its author's investigations into the possible role of a microsporidian in the etiology of yellow fever. It is particularly enlightening with respect to the direction being taken by its recipient. Lutz had just written “Waldmosquitos und Waldmalaria” on 16 September 1902. In June, he found himself in Rio de Janeiro to collect Stegomyia for the experiments that would commence in December. That same year, in partnership with Alfonso Splendore, Adolpho Lutz published the first in a series of three papers on pebrine and microsporidia. He released these in a German periodical (CentralBlatt für Bakteriologie, Parasitenkunde und Infektionskrankheiten), thus selecting as the audience a network of scientists that was still at a considerable remove from the network comprising Pasteur Institute investigators and the francophone majority of Brazilian doctors.

Pebrine was the name given to the infectious disease of the silkworm caused by Nosema bombycis Nägeli. These microsporidia had already caught Lutz's attention during his first study of Sporozoa, which resulted in the 1889 publication of the article mentioned earlier, addressing a different order of Protozoa: Myxosporidia. In this paper, Lutz had described a myxosporidian he had found in the gall bladder of Batrachia. Pioneering these studies in Brazil, Lutz highlighted the growing attention focused on the pebrine microsporidian in a paper he wrote with Splendore (1902). This growing interest was grounded not only in the practical aspects of sericulture (only recently introduced in São Paulo) but also in biomedical reasons: ever more discussions were exploring how this group of Protozoa behaved as cellular parasites, especially with respect to malignant tumors; furthermore, as we have just seen, speculations on its role as an agent of yellow fever were a topic of the day.

The first species of microsporidian – Nosema bombycis – was described in 1857 by the Swiss botanist Karl Wilhelm von Någeli

(1817-91).152 At that time, he thought the small black spots on the Bombyx mori moth were a yeast that belonged to the kingdom Fungi. More in-depth knowledge of this organism has been attributed to Louis Pasteur. In 1865, the French government commissioned him to investigate a disease that was devastating the silkworm. In 1867,

after various incorrect interpretations had been put forward, 153 Pasteur identified certain “corpuscles” (Nosema bombycis spores) as the cause of the pebrine disease, although he had never understood the true nature of the parasite (Hyman, 1940, p.162). It was only in 1882 that it would be included among protozoa. After a series of studies the French embryologist Édouard-Gérard Balbiani (1823-99) concluded that the Nosema described by Någeli bore greater affinity to sporozoa than to fungi; he then transferred it to the class Sporozoa, created by Rudolf Leuckart in 1879, and defined the taxon Microsporidia to include Nosema bombycis and the other species of

the group. 154

 

The Bombyx mori butterfly and its cocoon formed by threads of silk

used to weave that cloth that gave rise to trade relations between

China and the West. Source: www.tuttocina.it/Cina-

tour/VdS/Bmx_mori.htm, retrieved 27 June 2005.

Until a few years ago, microsporidia had been classified in the phylum Protozoa as an order within the subclass Cnidosporidia and the class Sporozoa, along with myxosporidia (Hyman, 1940, p.47; Store and Usinger, 1979, p.311).

Phylum Protozoa

Class Sporozoa

Subclass Cnidosporidia

Order Mysoxporidia

Order Microsporidia

These microorganisms caused a great stir in 1988 when they were discovered in HIV patients. After many studies into their taxonomic classification, it was established that myxosporidia are more closely related to Metazoa than Protozoa, and microsporidia, to fungi (Cox, 2002, p.595-612).

At the time that Lutz and Splendore published their paper, few species had been described and very little was known about these sporozoans. There was a consensus that they were intra-cellular parasites of a few vertebrates (fish) and, mainly, invertebrates. It was also known that they engaged in a form of hereditary transmission, by which the female host passed the agent of infection to the next generation through its eggs. Lutz found in Splendore the ideal partner for investigating these minute parasites, whose size demanded extreme patience and a great expertise in microscopy and also in fixing and staining techniques, knowledge that Splendore had acquired in Italy during his first few years in the profession. Lutz often calls attention to the patient work of his co-author: “Since there were few specifications on fixing and dying techniques, or on use of reagents, we paid these issues meticulous attention, with Dr. Splendore undertaking numerous lengthy experiments.” In another excerpt on silkworm reproduction, Lutz praised Splendore's skill in managing to obtain “a good number of healthy Bombyx mori eggs” (Lutz and Splendore, 1902, p.151).

Alfonso Splendore (1871-1953) associated himself to the director of the Bacteriological Institute of São Paulo as soon as he arrived from Italy in 1899. A graduate of Rome's Medical and Surgery Faculty two years earlier, he had worked as an assistant at Rome's Hygiene Institute, alongside such masters as Angelo Celli (1857-1914), Claudio Fermi (1862-?), and Giovanni Battista Grassi (1854-1925). When he moved to Brazil, he probably brought with him recommendations addressed to Lutz, who kept close ties with Italians who were studying malaria. In addition to working with Lutz at the São Paulo institute, Splendore was responsible for founding the laboratory at Rome's Umberto I Hospital. He also headed the

laboratory at the Beneficência Portuguesa Hospital in São Paulo.155 Apart from the three papers on microsporidia, Splendore worked on

a number of other papers with Lutz.156

In the first, they established new species that parasitized another group of insects, besides moths, and a species of fish. At that time it was not known whether moths were infected by other species of Nosema, besides Nosema bombycis, which Lutz and Splendore also called “pebrine.” They verified this with a butterfly quite common in the region of São Paulo (Brassolis astyra Godt), which Lutz had first examined when he began his studies on sporozoans in the 1890s. With Splendore, Lutz now demonstrated the spontaneous infectious process and its artificial transmission in a laboratory of other species of Nosema; they further verified the hereditary transmission of the infection – an issue, as we have seen, that greatly interested Paul-Louis Simond.

They carried out a series of experiments using healthy eggs from silkworm caterpillars obtained locally. With the help of Alfonse's

brother, Dr. Achille Splendore,157 they managed to bring in from Italy animals infected with pebrine, thus making possible comparisons and transmission experiments. They faced many difficulties, especially concerning classification of the species of host butterflies. Since there was no systematic classification of the Brazilian species, Lutz and Splendore were forced to rely on Adolfo P. Mabilde's work on butterflies of the state of Rio Grande do Sul and on the general treatise published by W. J. Holland in 1898, The Butterfly Book. They based themselves solely on the form of the spores in identifying the species of microsporidia. In his studies on myxosporidia, the Belgian scientist P. Thélohan (1892, 1895) had identified a polar capsule with a spiral filament in this group of microorganisms, but Lutz and Splendore did not consider it because they could not discern such a minute morphologic characteristic. They relied on another criterion to distinguish the species: their association with hosts. This was not an acceptable criterion according to the day's classification rules, and the authors themselves admit it: “It seems impossible to name species based solely on spore characteristics that appear in varying quantities; that is why we have adopted a method that is largely disapproved of today, which is to designate the species by the name of the first host in which it was discovered” (Lutz & Splendore, 1902, p.153).

In this article they identified nine new species of Nosema, most of which were Lepidoptera parasites. They verified that naturally occurring infections only had lethal consequences in silkworm pebrine. In the case of Brassolis astyra, São Paulo's common butterfly, an uncommon atrophy of the caterpillar was a sign of a very serious infection, but no visible symptoms were observed in other species. The authors observed that another butterfly, Dione juno, would go through normal metamorphosis despite extensive infection. It became clear that hosts who spent lengthier periods in the larvae stage on the one hand favored rapid propagation of the species corresponding to microsporidia and, on the other, favored the harmful aspects of this generally benign infectious process.

The work of these two scientists from the Bacteriological Institute of São Paulo attracted the attention of other researchers interested in the group. F. Mesnil wrote a review on it for the Bulletin do Institut Pasteur (1903, v.I, p.62). That same year, Paul-Louis Simond published a note in the Comptes Rendus de la Société de Biologie de Paris on Myxococcidium stegomyia, the microsporidium of the genus Nosema discovered in Stegomyia fasciata, initially in specimens that had drawn blood from a yellow-fever patient, leading the French bacteriologist to the supposition that it was the causative

agent of the disease.158

Lutz and Splendore also focused on the microsporidia that parasitized blood-eating hematophagous diptera and, in the paper published in 1904, they referred to “some forms” that had been recently observed, especially “parasites that one of us [Lutz] found in Simulium larvae.” They found different species of Nosema, which they described without, however, defining which genus they belonged to, for lack of specialized literature. This article was published in CentralBlatt für Bakteriologie, Parasitenkunde und Infektionskrankheiten as an addendum to the earlier one: in addition to describing new species, they included life-size drawings of the various hosts of microsporidia. The 1904 article benefited from an intense exchange of information between Adolpho Lutz and the Austrian lepidopterologist Joseph Foetterle, who lived in Petrópolis, then a spot favored by German and Austrian immigrants. Although he worked as a violin teacher at Colégio Sion in Rio, his passion was collecting butterflies. He had a good knowledge of insects and maintained close ties with physicians that were investigating transmitters, especially those who lived in or regularly paid visits to that pleasant mountain city. In the collection of Paul-Louis Simond, who became Foetterle's good friend, we find photographs taken by the Frenchman, showing the Austrian proudly displaying his collection. Foetterle also corresponded with Austrians and other Europeans and mediated relations between researchers who came to Brazil and the “natives.” In his letters to Adolpho Lutz, who was a close friend, he always kept him abreast of news on members of the French mission.

Foetterle was also involved in the search for new microsporidia. His correspondence with Lutz contains much important information on pebrine, dyes and butterfly classification. The director of the Bacteriological Institute would send Foetterle material to classify, while the Austrian would send him insects contaminated with pebrine. “I received your friendly card on Saturday and, on Sunday, the moth you sent, which belongs to the genus Caeculia (Fam. Lasiocampidae)” the Austrian naturalist wrote, for example, on 1 March 1903.

I am afraid that I can not tell what species it is. I have not yet

raised the species you sent me, but I am familiar with the

caterpillars of species that are very close to it … Regrettably, I

have but few duplicate samples of these rascals, which,

however, I could cede to you. The other day I finally found

pebrine in a species close to yours … It took me a while to find

these subjects that made such mockery of me, and it was a fair

amount of time and work that I spent on it. I do not have the time

to set them into permanent preparations today, but I will

certainly do so tomorrow and send them to you, along with the

moths. I have also experimented with pyoctanin as a dye, and

had quite good results. Have you also used this dye?159 In another letter, dated 19 October, which was sent along with more material, he states: “The species in which I found pebrine is in the paper tube … and I hope that this time you can confirm my findings and can also discover pebrine in the three preparations I am sending with it. If, once more, there are not any, then it is better that I stop

meddling in this.” 160

Foetterle's contributions were incorporated into the work of Lutz and Splendore, who did not fail to mention his valuable help.

FFoetterle in “colonial” clothing, gathering samples. Photograph

autographed by the subject on 25 April 1905. State of Rio de Janeiro

(Musée de l'Institut Pasteur, MP31328-2.tif).

 

Bufo marinus. Drawing at two-thirds of actual size (Brehm, 1925, v.1,

p.220).

Four years elapsed before the last paper in the series on microsporidia came to light in 1908, in the same German journal that

had published the other two.161 Its great merit lies in identifying worms and even other protozoa that served as hosts to microsporidia. As the authors themselves pointed out, it was already well known that these did not parasitize only arthropods and fish, but information was scant and incomplete (Lutz and Splendore, 1908). Lutz and Splendore described new species and identified others already described in hematophagous insects, such as Nosema simulii in Simulium larvae, Nosema chironomi in Chironomidae larvae, Nosema ephemerae in the intestines of ephemerid larvae, and Nosema stegomyia in the imago of Stegomyia fasciata. They found Nosema mystacis in two female samples of Ascaris mystax taken from the intestines of a cat, and Nosema distomi in a small Distomum that inhabited the intestines of Bufo marinus. In the Balantidium present in the terminal intestine of Bufo marinus, they found another microsporidium, Nosema balantidii. Lutz and Splendore came to the conclusion that these worms and infusoria were contaminated by direct infection, discarding the hypothesis of hereditary transmission.

They still had problems finding the polar filament and for this reason did not accept it as a valid character in identifying the species. Having found this morphological characteristic in only one species, they even raised doubts about its occurrence, reaching the conclusion that, in the future, its absence might prove important for the group's systematics. It was in fact later proven that all microsporidia spores have a long rolled-up filament that represents

the polar capsule (Hyman, 1940, p.162). 162

This was the last work that the two authors wrote on protozoa and also Lutz's last publication as head of the Bacteriological Institute of São Paulo. From 1919 to 1920, Splendore would teach bacteriology at the universities of Parma and Rome. In 1908, invited by Oswaldo Cruz, Lutz transferred to the Manguinhos Institute in Rio de Janeiro, where he would devote most of his time to an area of zoology that had won over his heart and his mind: entomology – which is, as he liked to say, “precisely” the topic of the next two books in this volume of the scientist's Collected Works.

 

Notes

1 Although evidence suggests that yellow fever had been present in Brazil since 1694 (Ministério da Saúde, 1971), it was only as of the mid-19th century that it became the country's major public health issue.

2 On magnetic tape, Bertha Lutz, daughter of Adolpho Lutz, recorded interesting facts about the family history and the life of her father. Entitled Lutziana, the tape registers in her own voice the outline of a biography she never came to write (BR. MN. [Brasil, Museu Nacional] – Fundo Adolpho Lutz).

3 On this point, see the interview with José de Barros Ramalho Ortigão Junior, published under the title “Recordações da infância: as primeiras letras com a família Lutz,” História, Ciências, Saúde – Manguinhos, v.10, no. 1, Jan.-Apr. 2003, p.420-4; in the same issue (p.13-83), see Benchimol, “Adolpho Lutz: um estudo biográfico.” See further Sá and Benchimol, “Adolpho Lutz: formação e primeiros trabalhos” / “Adolpho Lutz: Education and First Works,” by Benchimol and Sá (2004, p.118-84; 185-250).

4 Arquivo Nacional. Documents referring to Rio de Janeiro's Junta Comercial: 1872 – Liv. 648, Reg. 11424 G6, firma Lutz & Cia.

5 The bibliography of Adolpho Lutz compiled by Herman Lent (Neiva, 1941) was reprinted, with corrections and additions, in História, Ciências, Saúde – Manguinhos, v.10, no. 1, p.362-409.

6 Deane (1955, p.77-80). As this author shows, Lutz advocated the use of feces examinations to diagnose these helminthoses; he also pointed out that this practice was not given due credit even in the three German-speaking universities where he had studied. Lutz's biographers underscore his pioneer role in veterinary research. His first work in the area was the description of a species of Rhabdonema found in the domestic pig (1885). He wrote too about the role of fleas as hosts of Dipylidium caninum; about stephanurosis, cysticercosis, and other helminthiases common in animals; about Fasciola hepatica; and also about the wild hosts of Dioctophime renale, a parasite of the kidneys of several domestic animals.

7 See also Councilman and Lafleur (1891, p.396) and

www.whonamedit.com/doctor.cfm/2929.html (consulted on 13 Apr. 2005).

8 “Lõsch was the first author to provide a more accurate description of the amoeba species found in the stool of a patient with dysentery, accompanied by a thorough clinical record and an autopsy report. This was truly a pioneer study, containing excellent observations and descriptions of the organism called Amæba coli, to which very little was added subsequently” (Councilman and Lafleur, 1891, p.397).

9 “All his reports merely make mention of the existence of these microorganisms, without attributing any great import to them” (Councilman and Lafleur, 1891, p.400).

10 According to Councilman and Lafleur (1891, p.400-1), after LÖsch's, the most important study is the one that prompted Kartulis to publish a series of articles in Virchow's Archiv.

11 “His results were published in Czech, a language unfamiliar to most researchers … Kartulis mistook ‘O uplavici’, which in Czech means ‘About dysentery’, as the name of the paper's author … And thus the phantasmagoric professor ‘Uplavici, O.’ made his way into a number of specialized bibliographies, until Dobell untangled the confusion in 1938” (Martinez-Palomo, 1996).

12 Born in Canada, Osler had begun his clinical practice in Dundas, Ontario, but was soon appointed lecturer and then professor of physiology, pathology, and medicine at McGill University. In 1884, he took the chair in clinical medicine at the University of Pennsylvania, in Philadelphia. There he became one of the founding members of the Association of American Physicians. In 1888, Osler accepted an invitation to serve as the first professor of medicine at Johns Hopkins University Medical School, in Baltimore. Together with William Henry Welch (1850-1934), head of pathology; Howard Atwood Kelly (1858-1943), head of gynecology and obstetrics; and William Steward Halsted (1852-1922), responsible for surgery, they were to turn Johns Hopkins into one of the world's most prestigious medical schools (Risse, p.407; see also